Evaluation of the Awareness, Beliefs, and Psychological Impact of Patients with Alopecia Areata in Makkah City, Saudi Arabia

Methods A descriptive cross-sectional study was conducted among patients diagnosed with AA at different hospitals. A total of 211 patients were included in the investigation between November 2021 and June 2022. The participants were subjected to a well-structured, Arabic-based, validated questionnaire. Results More than half of the patients were men (54.0%) and single (50.7%). The most common age groups were 30 to 44 years (46.9%) and 18 to 29 years (36.0%). More than two-thirds of the participants (67.8%) had heard of AA before their diagnosis. Of these, the level of knowledge was low among 36.4%, medium among 42.0%, and high among 21.7%. Most of the patients believed that AA may be caused by genetic, nutritional, or health factors (77.3%) and that it is a serious health problem that necessitates treatment (64.0%). The most common psychological attributes caused by AA are feeling ashamed in front of other individuals (63.0%), anxiety (47.9%), and depression (36.0%). Conclusion Our results show more than two-thirds of the participants were knowledgeable about AA. Most believed that the cause of AA is genetic, nutritional, or health factors and suffered negative psychological effects. According to our study, high levels of anxiety and depression are closely associated with AA patients, which affect their quality of life.


Introduction
Alopecia areata (AA) is an autoimmune hair disorder [1]. It is characterized by round or oval noncicatricial patches of hair loss on the scalp or the body that may be revisable [2]. Its severity runs from small patches on the scalp to complete scalp hair loss (alopecia totalis) or the entire loss of scalp and body hair (alopecia universalis). AA is one of the most prevalent hair loss types, with a global incidence of approximately 2% [3]. In Saudi Arabia, the prevalence of the disease is higher than in western countries which may be due to the high consanguinity rate in Saudi Arabia [4].
AA demands a clinical-based diagnosis; however, a skin biopsy can be used in certain situations [5]. Family history and genetic factors play a major role in the pathogenesis of the disease and the environmental insult or psychosocial stress that afect its progression. As a lifelong disease, it has a signifcant efect on patients' emotional and psychological well-being. Patients with AA may experience anxiety, depression, and other psychiatric stress, which decreases their quality of life [6]. While AA is incurable, diferent modalities might help improve the condition, including topical treatment, local injections, systemic steroid and topical immunotherapy, minoxidil or anthralin, systemic immunosuppressants such as cyclosporine or methotrexate [3], and Janus kinase inhibitors such as tofacitinib and baricitinib.
Despite substantial progress in understanding the etiology of AA and its treatment options, the lack of knowledge and poor behaviors of patients with AA are roadblocks to successful treatment. Several studies have reported remarkably low levels of knowledge, beliefs, and perceptions of patients with AA, including studies in Pakistan [7], the Philippines [8], the United States [9], and Qassim, Saudi Arabia [10]. Coping with this hair loss experience is infuenced by the patient's understanding, perception, and knowledge of AA, which leads to greater adjustment. Ignorance and illogical conduct, on the other hand, amplify the harmful efects of AA [11].
Because available data on the awareness, knowledge, and perception of AA patients are limited in western Saudi Arabia, the current study aims to evaluate the awareness, beliefs, and psychological impact of patients with AA in Makkah, Saudi Arabia.

Study Design and Population.
A descriptive crosssectional web-based study was conducted between November 2021 and June 2022 using an online questionnaire which designed in Google forms and distributed among patients with AA in Makkah. Te authors reached those patients by reviewing the medical records in the dermatology department of three random hospitals in Makkah. We asked both genders above 18 years with a confrmed diagnosis of AA to complete the questionnaire. We excluded patients from any medical/health specialties (including medicine and surgery, dentistry, physiotherapy, laboratory medicine, and clinical nutrition) and those who refused to consent to participate in the study.
Te minimum sample size required for this study was calculated by OpenEpi version 3.0 [12], which uses the fol- , and we considered the population size of patients with AA as 741 patients based on the prevalence of patients with AA in Saudi Arabia [4]. Keeping the confdence interval (CI) at 95% and the design efect at 1.0, and considering the anticipated frequency as 10% [10], the sample size was calculated to be 117 participants. Nevertheless, the fnal number of included participants reached 211 patients.

Study
Tool. Data from patients with AA were recorded using an online questionnaire. Te participants were subjected to a well-structured, Arabic-based, validated questionnaire. Te questionnaire was inspired by a previous study conducted among 50 patients and published in July 2021 [7]. Te questionnaire consists of fve sections. Section one included patients' consent and agreement to participate in the study. Section two asked about demographic information, including age, gender, educational level, and marital status. Section three concentrated on the assessment of AA awareness. Section four asked patients to state their beliefs about AA. Te last section was concerned with the factors and psychological impacts of AA.

Validity and
Reliability of the Questionnaire. Te questionnaire was frst validated using content validity, with an assessment conducted by content experts. Tereafter, face validity was assessed by a medical educationist who found that the survey met the objectives of the survey and that the fow of the questions was in a logical sequence. To test the reliability of the questionnaire, a pilot study was conducted with 40 participants; the questionnaire was then modifed according to the respondents' feedback. Cronbach's alpha was calculated as above 0.7, which sufces for reliability.

Statistical Analysis.
Statistical analysis was conducted using RStudio (R version 4.1.1). Frequencies and percentages were used to express the categorical variables. Items with multiple responses were analyzed using the multiple response analysis technique. To determine the level of knowledge, multiple choice questions were used, and the right answers were given a score of "1," while the wrong answer or "I don't know" answers were given a score of "0." Participants who correctly answered 10-20% of the questions were labeled as "low level," 30-50% as "medium level," and >50% as "high level." Factors associated with knowledge on AA were assessed using Pearson's Chi-squared test or Fisher's exact test whenever applicable. Te signifcantly associated factors were further used as independent variables in a binary logistic regression model to investigate the independent predictors of favorable AA knowledge. Te results of the regression analysis were presented as the odds ratio (OR) and respective 95% CI. A p value of <0.05 indicated statistical signifcance.

Ethical Considerations. Te Institutional Review Board
(IRB) at King Abdulaziz Hospital, Makkah, Saudi Arabia, approved this study (IRB No. H-02-K-076-1021-584 Date: 2.11.2021). All the participants were provided with information on the study before answering the questionnaire. Te collected data were stored securely for research purposes, and electronic informed consent was obtained once the patient was approved to complete the questionnaire.

Sociodemographic Characteristics.
We received responses from 211 patients with AA. More than half of the patients were men (54.0%) and single (50.7%). Te most common age categories were 30 to 44 years (46.9%) and 18 to 29 years (36.0%). Patients with a bachelor's degree or diploma represented 58.8% of the sample (Table 1).

Source of Information on AA.
Te participants indicated that the most common sources of information were healthcare providers (59.7%) and the Internet (55.0%). On the other hand, the least common sources of information were social media groups (0.9%) and other sources (1.9%), which included information retrieved from other experienced individuals, scientifc research, and clinics ( Figure 1).

Characteristics of Disease Diagnosis and Management
Approaches. Te majority of the respondents revealed that they had been diagnosed with AA at dermatology clinics (67.3%), whereas approximately one-third were selfdiagnosed (35.1%). About half of the participants (50.2%) were directly referred to a dermatology clinic by a hospital, and the remainder were referred by a health center. More than three-quarters of the patients with AA (76.3%) had sought to visit hospitals and healthcare centers for the management of AA. By comparison, home remedies and traditional medicine were used by 59.7% (Table 2).

Knowledge on AA and Associated Factors.
More than two-thirds of the participants (67.8%) had heard of AA before their diagnosis. Of these, the level of knowledge was low (10-20%) among 36.4% of the respondents, medium (30-50%) among 42.0%, and high (more than 50%) among 21.7%. Notably, 27.5% of the respondents stated that they had a family member diagnosed with AA.
Regarding the factors associated with the respondents' knowledge on AA before their diagnosis, the results showed that knowledge was associated with educational level, with signifcantly higher proportions of uneducated participants (87.5%) and those who had obtained a bachelor's degree or diploma (73.4%) having knowledge on AA than those at other educational levels (p � 0.028). Furthermore, a significantly higher proportion of married participants had AA knowledge than those in other relationship categories (p < 0.001, Table 3). However, the results of the multivariate logistic regression analysis indicated that being married was the only signifcant predictor of favorable knowledge on AA (OR � 3.05, 95% CI � 1.59 to 6.03, p < 0.001, Table 4).

Beliefs about AA and Its Impact on Quality of Life.
Te majority of the patients believed that AA may be caused by genetic, nutritional, or health factors (77.3%) and that it is a serious health problem that necessitates treatment (64.0%). Additionally, 75.4% of the respondents thought that an efective treatment for the disease existed. Concerning the infuence of AA on the participants' lives, only 37.4% thought that it is difcult to live with AA and 40.8% indicated that the disease might alter their quality of life (Table 5).

Psychological Efects of AA.
A considerable proportion of the participants declared that AA negatively afects the psychological side (79.6%). Te most common psychological attributes caused by AA were feeling ashamed in front of other individuals (63.0%), anxiety (47.9%), and depression (36.0%, Table 6).

Discussion
Available data on the awareness, knowledge, and perception of AA patients are limited in Western of Saudi Arabia. Hence, Te Kingdom of Saudi Arabia is characterized by the large geographical area and the diferent traditions in each region. As instant, the consanguineous marriage is known to be higher in some regions compared to others, which afects the rates of disease, respectively. Accordingly, our current study focused on studying one of the vast regions of the Kingdom. Tis descriptive cross-sectional study aimed to evaluate the level of awareness, beliefs, and psychological impact of patients with AA in Makkah, Saudi Arabia. Te fndings showed that the level of knowledge was low among 36.4% of the respondents, medium among 42.0%, and high among 21.7%. Furthermore, the largest proportion of the participants believed that AA may be caused by genetic, nutritional, or health factors and that it is a serious health problem that may afect quality of life (40.8%); only 37.4% of them thought that it is difcult to live with AA. A large proportion of the participants declared that AA negatively afects the psychological side and stated that the most common psychological attributes caused by AA are feeling ashamed in front of other individuals, followed by anxiety and depression.
In our study, we reported that AA is slightly more prevalent among men than women; previous studies have reported similar fndings [4,7,9]. However, the latest article published by the National Institute of Arthritis and Musculoskeletal and Skin diseases reported that both genders might develop AA with an equal chance [13]. Regarding patients' sources of information on AA, our study indicated that the most common sources were healthcare providers (59.7%) followed by the Internet (55.0%). Tese fndings demonstrate the huge dependence on the Internet. Several studies have found that the rising amount of OHI may afect the physician-patient relationship by infuencing patient behaviors [14,15]. Although OHI does make patients aware and knowledgeable of their condition, enhance their decision-making, and improve their self-confdence when communicating, an uneven quality of OHI may lower patients' understanding and health behaviors [16]. Te key factor to ensuring that OHI benefts the physician-patient relationship is to enhance people's health information literacy and the quality of OHI. Regarding demographics, marital status was a signifcant factor, as married participants had higher levels of knowledge (p < 0.001). Although the association between marital status or age and the risk of AA is unclear, it has been observed that elderly patients, especially women, are more susceptible to developing AA after sustaining severe trauma or bleeding or sufering psychological stress [17]. By contrast, studies have reported the incidence in children to be around 2.7% [18]. Higher levels of knowledge among married participants may be age related or due to the higher levels of AA among their social circles, which makes them more vulnerable to gain knowledge about the disease.

Advances in Medicine
A previous study found that the impact of AA on quality of life was more profound within the married category than among the unmarried. Tese results showed that the greater number of responsibilities among the married make them worry, leading to psychological distress [7]. Our study showed that 37.4% of the participants thought that it is difcult to live with AA, while 40.8% indicated that the disease may alter their quality of life (Table 5). In addition, the majority of our participants sufer lower psychological health as a result (79.6%). Feeling ashamed in front of people is the major psychological efect in our study (63.0%), followed by anxiety (47.9%).
Te dilemma of the impact of AA on quality of life has been widely studied globally. Previous meta-analyses have been carried out in the United States, Italy, France, Brazil, Belgium, China, Korea, Japan, Turkey, Iran, Tunisia, and Kuwait. Tese studies have revealed that AA patients have signifcantly impaired health-related quality of life, especially mental health [19]. Te disease not only has a severe psychological impact but also causes a marked disturbance in the social life of patients, forcing them to avoid social gatherings, change their hairstyle, and alter the type of clothing they wear. Compared with the general population, AA patients presented a signifcantly altered quality of life,

Advances in Medicine
where patients with a 51% to 75% hair loss showed signifcantly lower scores on the social functioning subscale than those with a hair loss of less than 25% [11]. Tus, paying attention to the psychological sensitivity of AA patients is crucial. In addition, ofering a suitable psychiatric/psychological intervention, including psychotherapy, relaxation techniques, antidepressants, group therapy, and hypnosis, might be a life changer [20][21][22].
Our study reported that more than two-thirds of the participants (67.8%) had heard of AA before their diagnosis. Of these, 42.0% rated their level of knowledge as medium (30-50%). Muhammad and colleagues reported that the majority (62%) had no knowledge on what causes AA (p < 0.05) and that 30% considered it to be a serious health issue. A signifcantly (p < 0.05) higher number of patients (78%) perceived that AA has no association with diet and almost half (42%) of participants believed that germs and viruses cause AA [7]. Al-ajlan et al. noted that family history is an important factor in AA, as 37% of their participants with AA also had a frst-degree relative with the condition [4]. Our study supports the fnding that family history is an important factor in AA. Notably, 27.5% of our respondents stated that they had a family member diagnosed with AA.
Our study represents an evaluation of the awareness, beliefs, and psychological impact of patients with AA in Makkah, which demonstrated a good level of knowledge but high levels of anxiety and depression. Tis fnding has a great clinical implication for the crucial need for psychiatric/ psychology integration in the management of AA patients which may, in turn, refect on their quality of life. Our study includes several limitations to disclose. First, an online platform-based study may limit the generalizability of the study's results. Second, reporting bias is possible as our study depends on self-reported information of the patients. Lastly, the current study used a cross-sectional design which precludes the ability to deeply understand the causation between associated variables.

Conclusion
Our results show that more than two-thirds of the participants were knowledgeable about AA. Most believed that the cause of AA was genetic, nutritional, or health factors and sufered negative psychological efects. According to our study, high levels of anxiety and depression are closely associated with AA patients which afect their quality of life. As AA is one of the most common hair disorders, adequate psychological evaluation for patients with AA is needed to determine the efects of the disease. Tis article can be a preliminary step toward understanding the psychological impact, beliefs, and awareness of AA patients.

Data Availability
Te data supporting the current study are available from the corresponding author upon request.

Conflicts of Interest
Te authors declare that there are no conficts of interest.  6 Advances in Medicine